Headaches and COVID-19: What's the connection?

Gina DiPietro

Initially, the COVID-19 virus was identified mainly by fever, cough and difficulty breathing. But then headache became a dominant symptom. And for many patients their headache pain lingers long after they've overcome the virus. Welcome to Novant Health healthy headlines. I'm Gina dipietro. In this episode, Dr. Megan Donnelly, a Novant Health women's neurologist and headache specialist talks to Cliff Mertens about what a COVID-19 induced headache feels like, and how doctors are treating that new wrinkle. She also offers some tips on what you can do to reduce stress, which can often trigger migraine headaches. Thank you for listening.

Cliff Mehrtens 0:46

What is the connection between migraines COVID-19 or just Is it a thing? Yes. So it is so um, interestingly, there are multiple neurologic manifestations of COVID.

Megan Donnelly 1:00

In terms of more ominous things, there's encephalitis seizures, increased risk of stroke, increased risk of cerebral venous thrombosis,

hemorrhagic encephalitis, there's a lot of things that we've been seeing along with even things like transverse myelitis, a condition called a dam and other acute myelinating disease that looks like a new onset really kind of florid Multiple Sclerosis attack.

And things like Yeon, Brae, which we've seen with other viruses, as well. But this one is behaving very differently than a lot of other viruses in the past. And one of the thoughts is that it appears that one of the very first symptoms that people have, even before they develop cough, is they will first get an osmia, which is lack of sense of smell. And then they can get if they're going to get headache, they can get really bad headache at that time. And then sometimes cough doesn't even come until another couple of days later. So there's theory that this this nausea is actually due to the virus crossing over and invading the cribriform plate and so that that's the initial neurologic manifestation. Because that's your olfactory bulb, which part of your, your one of your cranial nerves.

I personally at the beginning of this in March, I was very, very stressed just about the pandemic itself, I have several very important family members to me, who are immune compromised. And so my my profound level of worry was that beyond a normal stressor, I recognized in myself that that was toxic stress levels. And I started doing more practice of yoga and mindfulness meditation, deep breathing, because I knew that I needed to do that. Sometimes that's not enough, though. And so although i think that that's an important first mainstay of treatment, if it's not enough, then we need to recognize when we need to treat patients with medication and with psychotherapy to help. So if it's really the the stressors that are going on, that are the biggest cause of the uptake of headache, addressing those rather than just throwing more meds at the headache is going to be extremely important. So as with any health condition, treating the underlying cause of uptick

So from a headache perspective, yes, this, this has actually been found to be one of the presenting symptoms of COVID. So when I'm seeing somebody who, by the time they're I'm seeing them, oftentimes, they've already been diagnosed with COVID. And I'm seeing them for their headache, either there in you know, we have a local virtual hospital. So patients will be at home in virtual hospital, but then doing video visits with me. And that's been speaking of being able to offer video visits, it has been a wonderful resource for these patients to be able to have video visits, while they're sick while they're at home. But still get acute and adequate quality neurologic recommendation and care while they're at home and not be told, oh, well, you're sick right now, nobody can see you right now. And so I'm seeing them while they're actively sick. And I'm seeing also patients in follow up, you know, two weeks months later, after they've recovered from COVID, but they're still having post COVID headache. What it's presenting as is mostly kind of whole head, severe pressure pain. So it's presenting differently than that of migraine, which by definition is this International Classification of headache disorders, three criteria for migraine, which is unilateral throbbing with sensitivity to light or sound, or nausea. And this is more of a whole head pressure presentation. Um, and so so with this, the one of the concerns, obviously, I have to rule out and make sure I'm not missing one of the more ominous conditions. And so I often have to order imaging on these patients and I'll get an MRI make sure that they're we're not seeing stroke or encephalitis. And I'm getting venous imaging to make sure I'm not missing a venous clot, which is called a cerebral venous thrombosis. The reason for that is these patients are quite hypercoagulable from COVID. And so, so because we know these patients are hypercoagulable. I'm following current guidelines which are ever changing. And one of those things is starting them if they're actively sick with COVID on aspirin therapy based on this recommendation, to help decrease the risk of being hypercoagulable. And then managing their head pain and the ways that we do that. And this is unpublished data, but this is what's coming out of new New York where obviously they had their search before we did. And so we're getting some really helpful info on that. They're using gabapentin as one of the preventative treatments for this. We're in the process right now of writing up a case series of all of our patients from around the country who have who have COVID and headache. So I'm, it's going to be nice when we actually get that published. But I think it's going to be a very important piece of literature for everybody who sees COVID patients in treating that are our headache patients.

Cliff Mehrtens 5:40

Is it still too early in the process of COVID to I mean, obviously, you can't do a large study and ended up study because it's still fresh and new. To to form any sort of theories or anything. You're sort of like, battlefield in it right now. Sounds like as opposed to we studied this for five years, because you haven't had five years.

Megan Donnelly 6:00

Correct. We've had a couple of months. So yeah, so we don't have any randomized controlled trials. What we have are on the ground in the battlefield, advice that gabapentin nightly 300 to 900 milligrams, each night has looked helpful for these patients who have post COVID lingering headache, who we know have, at this time, normal resolved brains, so we're not seeing strokes, encephalitis, clots or anything. So you know, they're radiographically normal patients. It looks like gabapentin is helpful. But you're right, there isn't anything randomised controlled about it, it's the same way that we're having to do everything with COVID, which is by the seat of our pants.

Cliff Mehrtens 6:46

Um, what about migraines, and triggers? I'm guessing a stressful situation like everyone is in probably doesn't help some people who deal with that on a pre COVID basis to just if stress triggers them, obviously, they have more these days. Well, how do you deal with that? What do you suggest for someone who might be facing that battle?

Megan Donnelly 7:08

Great questions. You know, we're all weathering the sto...